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Nguyen Trong Hoa has been injecting heroin for 19 years but in January he finally knew he had to get help. He began methadone therapy to help break his habit and also had an HIV test at an outpatient clinic in Thanh Hoa City on Viet Nam’s north central coast.

Hoa, 36, was worried when he learned that he was HIV-positive. But the clinic that tested him is participating in a pilot study supported by WHO to start HIV-positive drug users on antiretroviral therapy as soon as they are diagnosed – in line with the Organization’s recommendation to give people treatment before HIV weakens their immune system.

The aim of the study is to assess the impact of targeting people like Hoa with the “test and treat” approach, both on their own health and on reducing new HIV infections. Hoa didn’t hesitate when he was asked to take part.

An estimated 257 000 people are living with HIV in Viet Nam, many of them drug users. “HIV-positive people who inject drugs face heavy stigmatization. They are intent on keeping their HIV status secret from family and community, which often results in their seeking testing and treatment at a very late stage of infection,” says Dr Loc Thanh Hai, Chief of the Outpatient Clinic at the Thanh Hoa City Health Centre.

Real world challenges

Antiretroviral therapy (ART) slows the spread of HIV. So delaying treatment too long may leave an individual more vulnerable to infections such as tuberculosis, and render any eventual treatment less effective. Studies indicate that starting ART early not only benefits the patient but can reduce the risk that they will pass the virus to someone else if they share needles or have unprotected sex.

The study, launched in April 2014, will enrol some 300 HIV-positive drug users at 13 outpatient clinics in Thanh Hoa and Thai Nguyen provinces. Participants will be provided with information about the study and will receive ART and voluntary HIV testing and counselling. The study will also track how well participants adhere to treatment, and researchers will interview medical staff and patients to assess how feasible and acceptable the programme would be in the long run.

WHO is involved in advocating, convening and supporting studies to inform Government policies for effective HIV programmes on the ground, especially for groups that are hard to reach because their behaviour is often stigmatised or criminalised, such as injecting drug users, men who have sex with men, and sex workers.

“It is of vital importance to understand, how earlier treatment, proven effective in reducing HIV transmission in serodiscordant couples in clinical trials, can be implemented in the real world, above all with regard to these key populations,” says Dr Ying-Ru Lo, HIV specialist at WHO Regional Office for the Western Pacific.

Brighter future

Thanh Hoa and Thai Nguyen provinces were chosen for the Viet Nam study because a joint WHO and UNAIDS initiative, known as Treatment 2.0, is being simultaneously rolled out there. These programmes provide HIV testing, counselling and treatment closer to where people live and work, usually at a communal health stations. The aim is to make it easier, and cheaper, for people to be checked, get medication and continue treatment.

“Our hope is that by prioritising these people with early ART while continuing an optimal mix of prevention methods, we will be able to see a huge reduction in HIV new infections and AIDS deaths, that is not only cost-effective over the long term but prevents a huge amount of individual suffering,” says Dr Bui Duc Duong, Deputy Director General, Viet Nam’s Authority for HIV/AIDS control.

“Viet Nam has been very progressive in tackling HIV by promoting needle-syringe programmes, methadone maintenance therapy and condom use among high risk groups and it is now time to accelerate access to HIV testing and treatment, especially for people who inject drugs,” says Dr Masaya Kato of WHO Viet Nam office.

For Hoa, the future is already looking brighter. “Since being on ART, I feel more confident and worry less about dying. I can look forward to continuing my life with my wife, who knows my HIV status and is very supportive,” he says.

Fact box: CD4 count

Testing how many blood cells known as CD4 a person has can give an indication of the strength of their immune system. Viet Nam’s guidelines say HIV-positive people whose count is 350 or below should get ART. Often drug users seek help when their count is below 100. Another factor is a patient’s viral load, which means how much HIV there is in a body fluid.

When to start ART depends on a number of factors and WHO is continually evaluating its guidelines. The current recommendation is to start ARVs when the CD4 count is 500 cells/mm3 or less.